With increase in aging population globally, prevalence of non-communicable diseases such as frailty and dementia will increase putting a strain on the finite healthcare resources. Healthy aging is defined as the process of developing and maintaining physical, social, cognitive and mental health with the aim of delaying the onset of disability.¹⁾ A number of separate interdependent protective social determinants of health (SDOH) factors are known to influence healthy aging and improve resilience amongst community dwelling older adults. These factors include financial security, social participation, mobility, physical, cognitive, and mental health, and age-friendly neighbourhoods. Individuals who are disadvantaged in SDOH experience overall poor health and premature mortality.²⁾ The coronavirus disease 2019 pandemic and its associated lockdowns significantly impacted physical and mental health of older adults, leaving many lonely, with poor social support, and disconnected from essential services. This has led policymakers to recognize the impact of SDOH on health risks, outcomes, and resilience.³⁾ Health and social care often exist in silos, with lack of coordination and information sharing.⁴⁾ Additionally, healthcare professionals are not often trained to address SDOH, nor are they aware of available evidence-based interventions in the community.

Social prescribing (SP) is an innovative approach that bridges health and social care interventions. It recognises that health outcomes cannot be fully addressed by medical treatments alone. Instead, SP aims to address SDOH factors beyond clinical care that impact well-being. The concept of SP was first introduced in the United Kingdom (UK) in 1990’s in response to the trend that up to a quarter of patients in the UK were visiting their primary care providers for social issues which would have impacted medical outcomes and they could have been better served by navigators or link workers.⁵⁾ SP connects patients with non-medical needs to the support system provided by the community and non-governmental organisation with the aim of improving overall health, wellbeing, social isolation and disease prevention.⁵⁾ SP encompasses a wide range of interventions that address various SDOH factors, including lifelong learning, financial advice, healthy aging programmes such as gardening, loneliness, and isolation by encouraging social participation, bereavement counselling, physical activity, and group-based activities.⁶⁾ Research has shown that SP leads to improvements in mood and psychological well-being.⁷⁾

Similar to the National Health Service (NHS) Long-Term Plan where SP has been incorporated in the comprehensive model of personalised care, a major reform was introduced in Singapore in July 2023 known as the Healthier SG. This reform aims to create a "health" ecosystem focused on preventive care. By leveraging primary care providers and community partners, it aims to enhance personalized care plans and promote SP.⁸⁾ In addition, the Ministerial Committee on Ageing for Singapore updated the Action Plan for Successful Ageing in 2023 centering around three themes: care, contribution, and connectedness further highlighting the important role of SP.⁹⁾ Despite these advancements, diverse concepts and practices persist regarding what constitutes SP. Interventions vary in terms of their aims, referral routes, partnerships and methodologies.¹⁰⁾ Healthcare workers, especially clinicians, are often unaware of community resources related to SP or struggle to connect patients to them.¹¹⁾ Clinicians sometimes tend to "overmedicalize" health problems, resulting in increased healthcare utilization.¹¹⁾

SP is nascent but growing in Singapore and Asia. As we design and develop SP programmes that are contextualised to the local culture and community setting, understanding the knowledge and perceptions of health and community care workers towards SP becomes essential. This understanding will guide the training and development of this important intervention.¹²⁾ There are very few studies on health and community care workers’ knowledge and perceptions of SP, particularly outside of the UK. Given the growing development and implementation of SP in Singapore, we aimed to survey health and community care workers’ knowledge, perceptions of SP and barriers to SP across various healthcare settings.

In total, 123 participants participated in the survey. Of these, 35.8% were nurses, 16.3% were primary or subacute care doctors, 14.6% were acute hospital doctors, 13.0% were allied health professionals and 20.3% were others (Table 1). They had a mean age of 39.0±10.0 years. The majority were female (75.6%) with a female preponderance amongst nurses compared to other professions (p=0.002). Nurses had significantly more years of experience (50.9% more than 10 years of experience) than the other professions. Almost two-thirds (65.0%) of respondents had heard of SP. While approximately three quarter of primary and subacute care doctors and other healthcare staff had heard of SP, there was a significantly lower proportion among acute hospital doctors (55.6%) and nurses (56.8%) who had heard of SP (p=0.019).

Participants were asked what percentage they thought social determinants of health contribute to premature death in intervals of 10%. The majority in each job group chose 50% with no significant difference amongst the professionals. Among them, 48.8% had heard of the National Action Plan for Successful Ageing,¹⁴⁾ and 43.1% were aware of the Singapore Physical Activity Guidelines (SPAG). Over half (51.2%) responded that they had never encouraged their patients to follow the SPAG recommendations on physical activity. A quarter of health and community care workers had never referred for SP.

In terms of responsibility for SP, community nurses (90.2%), primary care physicians (81.3%), and active ageing centres (77.2%) were the top three professionals selected by survey respondents. Loneliness, older adults, stress, and anxiety were selected as the top groups/conditions that would benefit the most from SP. Physical activity, nature walks, and volunteering were selected as the top three types of SP activities. All activities listed in the survey were selected as SP activities by 80% or more of respondents, except for religious activity, which was chosen by 69.8% of respondents as an SP activity. Of the local exercise providers, 51.5% of respondents were aware of ActiveSG which is a national movement for sport that is run by the Singapore Ministry of Culture, Community and Youth. This was followed by the local Health Promotion Board (HPB) activities (45.0%) which organises various health, exercise, and nutrition activities across the different neighbourhoods in Singapore.

Overall, 58.5% of all respondents were aware on how to refer patients for exercise and 55.3% were aware on how to refer to social activities (Table 2). Only 39.9% responders knew how to prescribe exercises based on their function and clinical condition, highest amongst allied health staff (56.3%) followed by primary and subacute care doctors (50.0%) and acute hospital doctors (44.4%). Only 18.7% agreed or strongly agreed that exercise prescription is well taught in healthcare setting, highest amongst allied health staff (39.3%) followed by nurses (20.4%). The majority agreed (51.2%) and strongly agreed (44.7%) that SP is beneficial for patients’ mental health while 54.5% agreed and 32.5% strongly agreed that SP is useful in reducing healthcare utilisation. Similarly, 60.0% agreed and 16.0% strongly agreed that SP can help improve nutritional intake in seniors.

The most cited barriers towards SP were seniors’ reluctance (63.4%), lack of knowledge on how to refer (59.3%), lack of time (44.7%) and cost to seniors (44.7%) (Fig. 1). Among health and community care workers, allied health professionals reported the highest level of lack of knowledge on how to refer for SP (87.5%), which was significantly higher than other groups (p=0.023). Primary and subacute care doctors (75.0%) had the highest proportion reporting the lack of time as a barrier compared with other job groups which had the lowest proportion (20.0%) reporting this as a barrier. A clear majority indicated that training on SP (82.9%) and providing a list of exercise venues (80.5%) would encourage SP, whereas only 37.4% indicated that reimbursement would do so (Fig. 2).

Our study is one of the first few in Singapore and Asia Pacific region to explore knowledge, attitudes and barriers related to SP. Almost two thirds of the respondents knew what SP is, while one quarter had never participated in any SP activities. Awareness of SP was significantly lower amongst acute hospital doctors and nurses compared to allied health and community care workers. Slightly less than half of the respondents acknowledged that SP was everybody’s responsibility. Three quarters of health and community care workers agreed that SDOH contribute towards premature death in more than 50% of older adults. This finding aligns with studies showing that SDOH mediate 50% to 60% of the risk of premature deaths^14-16) and play a significant role in disease onset and progression, frailty and dementia.^17,18) Recognizing the role of SDOH in reducing health disparities, and its value in preventive care, healthcare systems globally are shifting from reactive acute care-centric models to population level proactive care.^19,20) SP as a non-medical approach, can effectively address social determinants of health and, if implemented well, create a sustainable ecosystem to improve overall population health.

The concept of SP is not new, but only recently become more formalised, with indications and referral pathways in many countries especially in the UK NHS. Our survey revealed that participants were keen to refer patients for SP, and the vast majority believed that SP would help reduce healthcare utilization and improve mental health. However, this enthusiasm was not supported by knowledge on how to refer patients for SP or awareness of exercise prescription guidelines. These findings align with results from other studies^13,21) which also identified inconsistencies in knowledge amongst healthcare professionals and SP providers. These findings emphasize the importance of cultivating buy-in from healthcare professionals for SP schemes.²¹⁾ For SP to be effectively established, health and community care workers need education about social interventions, guidance on local resources and guidelines, and the ability to "prescribe" social interventions to older adults. There was also no consensus as to who should be responsible for SP.

The top three perceived barriers were seniors’ reluctance, lack of knowledge on how to refer, and lack of time. Currently, there are no link workers in the Singapore healthcare ecosystem. A link worker is defined as someone who is "medically trained and specialises in referring people to services outside the health system which offer the opportunity for health, wellbeing and practical and emotional support."²²⁾ Link workers are also referred to as SP workers, support brokers and community navigators.²²⁾ To date, only one published model has been implemented by a local community hospital using well-being coordinators to help admitted patients reintegrate to their communities post discharge.¹²⁾ The ongoing discussion revolves around identifying individuals within our healthcare system who could take on the role of link workers. This may involve formal creation of such roles or revision of existing roles, and it will require collaboration among multiple stakeholders and leadership.

There is increased heterogeneity with aging and older adults have diverse needs. Functional ability is determined by interaction between environment, social support and intrinsic capacity which includes sensory, cognitive, psychological, nutrition, and mobility domains. The SP needs to be personalised and targeted with specific outcomes in mind. The type of patients who were thought to benefit from SP based on respondents reply include older adults, lonely or isolated, stressed, or anxious and depressed. SP has shown to benefit all groups of older adults and there is no one size fits all. It is often called shared care plan or anticipatory care plan where it needs to be tailored to personal preference, functional ability, and co-created with the residents to promote greater adherence. Digital platforms which integrate medical records, social and functional measures may be a potential path forward in refinement of SP, personalised assessment and patient engagement.²³⁾

Almost three quarter of respondents agreed that older adults with functional limitations will benefit from social prescribing, lowest amongst acute hospital doctors. Less than half were aware of the SPAG guidelines and similar proportion never encouraged patients to follow the guidelines. There are various community stakeholders who have been tasked to lead the implementation of physical exercise in the community setting such as the HPB, ActiveSG, People’s Association or Active Aging Centres. Only half had knowledge on exercises provided by the HPB with lowest knowledge amongst doctors and allied health experts. Slightly more than half were aware of ActiveSG with lowest knowledge amongst acute hospital doctors. Gym Tonic machines are located across Singapore in more than 30 different locations with the goal to expand to 50 sites by 2050.²⁴⁾ However, less than one quarter were aware of it. One third were not aware of any of the exercise providers.

Only one third of the responders knew how to prescribe physical exercise, and less than one in five agreed or strongly agreed that exercise prescription is well taught. Healthcare professionals did not perceive that exercise prescription was taught well in healthcare training with medical doctors rating this the lowest. SP is growing as a student movement worldwide.²⁵⁾ The establishment of the Global Social Prescribing Student Council has led to the development of the Social Prescribing International Student Movement Framework.²⁵⁾ While SP has been adopted as part of the curriculum in some medical schools around the world , it is not yet part of the curriculum in Singapore.²⁶⁾ Even as our health system looks to adopt and scale up SP across the country, we should plan for the education of future healthcare professionals on the impact of social determinants of health and interventions to address these such as SP.

Almost all agreed that lonely and socially isolated older individuals will benefit from SP. However, only slightly more than half of the respondents knew how to refer patients for social activities. Up to one in two older adults are at risk of social isolation and one in four lonely.^27,28) Social participation has a protective effect on health, quality of life, cognitive, mental, and physical health.^29,30) Social isolation in older adults has been associated with increased healthcare utilization such as hospital readmission and primary care visits, morbidity and mortality rates.^31,32) Impact of social participation on mortality is comparable to quitting smoking and exceeds other risk factors such as physical inactivity.³³⁾ A recent meta-review highlighted that group based activities with a collective purpose where residents had autonomy, learnt new skills inclusive of educational component and had a role in the development of the interventions were more effective.⁴⁾ A similar program locally which fulfilled all the requirements and was effective in improving social participation and other health measures is the Healthy Ageing Promotion Program for You which is now under the purview of the HPB.^34,35) The same review recommended many effective interventions such as inter-generational interventions, "conducive communities," psychological therapy, recreational activities, personalised social risk assessment and interventions. Interestingly in the same review, nonhuman companions and telehealth were effective in >60% in improving depression and anxiety.

Malnutrition and its precursor, anorexia of ageing (AA) are prevalent amongst older adults.³⁶⁾ It is estimated that around 27% of community dwelling older adults and up to 50% of those in healthcare settings are at risk of malnutrition.³⁷⁾ Social factors such as loneliness are well established risk factors for AA and malnutrition.³⁸⁾ Increased social interactions and participation have been shown to be positively associated with food intake.³⁹⁾ Nutritional risk and AA are associated with many negative consequences such as weight loss, frailty, sarcopenia, physical and cognitive functional decline, decrease in bone mass, reduced quality of life and increased mortality. Further studies are needed to assess the effect of SP and improving social isolation to improve nutritional intake and consequent health outcomes and quality of life. Locally, initiatives to simultaneously tackle social isolation, nutrition and physical frailty include the Share-a-Pot programme⁴⁰⁾ where older adults meet at centres within their communities to exercise, socialise and enjoy a bowl of nutritious soup together. Community kitchens have also been set up to promote communal cooking, dining, and building of relations in local communities.

There are limited studies on barriers and facilitators to SP. Facilitators and barriers were related to heterogeneous implementation approach, legal agreement and data sharing, seamless communication between different stakeholders, local culture, adaptability, and infrastructure.⁴¹⁾ In addition to barriers cited above, other barriers identified from our study include lack of time, cost to older adults, and the complexities of data sharing and referral systems. Reluctance of seniors was the top cited barrier to SP. Low patient engagement has been found to be a major barrier to the implementation and delivery of SP services.⁴¹⁾ There are many reasons for low patient engagement including lack of interest and scepticism over its potential benefit, patient and family mindsets, low motivation, difficulties faced by healthcare professionals in explaining the concept of SP, financial and transport issues.⁴²⁾ Exactly which factors impact the decision calculus of patients in our local context will require further study. Encouragingly, few responded that SP was not their job to do so.

The successful implementation and iteration of SP in our local context will depend on addressing these barriers faced by health and community care workers, older adults, service providers and policy and systems levels. Our respondents agreed that two main factors which would facilitate SP would be training and making a list of community resources available. Only a third felt reimbursement was important. Currently, the various SP stakeholders have their own referral and tracking platforms, some have monthly subscription charges. However, most of these platforms lack clear guidance on who will benefit the most from SP. As much of the digital and human resource infrastructure for SP has yet to be developed in Singapore, a cohesive, systems- and evidence-based approach to the implementation and delivery of SP as part of a nationwide framework has the potential to scale up SP rapidly and effectively across the country.

Our study is not without limitations. Firstly, as an online anonymous voluntary survey, participation bias is inherent to this survey approach. Non-responders may possess shared characteristics, such as unawareness of SP, or caseload pressures, which may have affected their participation. Accounting for these factors may underestimate the findings with possible higher responses on unawareness or lack of time. Secondly, there is no public data on overall demographics of the healthcare workforce, and thus obtaining a representative sample would be difficult to ascertain. This limitation was further compounded by the relatively small sample size, which may limit generalizability of the findings. Lastly, the survey pool was based on that of two acute hospitals in the western region of Singapore and the regional health network and may not represent the health and community care workforce of the entire country. Nevertheless, as an initial survey of SP which is developing in Singapore, these findings are useful to inform gaps in knowledge, training, and implementation of SP. Longitudinal studies to assess the evolution of these findings would be useful as SP further develops here.

Our study identified significant gaps in knowledge and attitudes towards SP. SP is not a single intervention but a programme with many interacting elements across different care settings. Its success is dependent on relationship between different stakeholders and patients, perceived benefits, and adaptation to local socio-cultural and healthcare contexts.⁶⁾ A robust and practical decision tool possibly incorporating augmented intelligence shared across different stakeholders is needed. This tool should incorporate medical records, SDOH, an inventory of interventions, and a reward system for both patients and referrers. Rigorous evaluations of SP and the implementation of SP programmes are lacking.²¹⁾ More studies are needed to evaluate the cost-effectiveness of SP in different populations groups and intended outcomes such as functional ability, economic benefits, and potential cost savings to the healthcare system and society as a whole. In addition, factors affecting sustainability such as the barriers and facilitators of implementation need to be measured using a standardised evaluation protocol such as the AIM-IAM-FIM (Acceptability, Appropriateness, and Feasibility of Intervention Measure) framework. Other factors which need to be evaluated include adequate provision of SP activities in various ethnic groups, marginalised and underserved communities, and its long term impact on changing the aging trajectory.

In conclusion, this study provides insights into health and community care professionals’ awareness, perceptions, and practices of SP in Singapore. We found that healthcare professionals believed that SP would help to reduce healthcare utilisation and improve mental health, were keen to refer for SP but there is room to improve awareness of how to refer to SP and knowledge of relevant exercise and physical activity guidelines.